Question: "I recently started working in a clinic whose population does contain a large number of current and former drug addicts.  Many have chronic pain issues and have been started on narcotics by other providers without trials of non-narcotic managment. What are/where can I find the current guidelines regarding using narcotics in current/former addicts with pain and how do you get them off of the narcotics?????"

Answer:  This is a situation that plagues many physicians on a day to day basis.  Pain is likely the most difficult symptom to treat in individuals in recovery from drugs and alcohol--and even more difficult in those who are still actively using.  Tapering narcotics in anyone can be especially difficult, but I typically use the following rules of thumb:

1. Try every single non-narcotic pain regimen known (including complementary and alternativce treatments) before accepting the risk of narcotics.
2. Have the patient keep a pain log over a period of time, so you can see variations in pain and objectively (as much as that is possible) quantify the pain.
3. If you have to use narcotics, educate the patient on the risk of addiction either to the pain medication, or relapse to the substance they previously used.
4. Before prescribing opioids in an individual with a history of addiction, have them sign an agreement that states:

• an agreement to submit to random urine drug testing
• an agreement not to get prescriptions for pain meds from any other provider under any circumstance, and the understanding that such behavior will result in your discontinuing your narcotic prescriptions
• an agreement to fill narcotic prescriptions at only one pharmacy so you can monitor their fills
• an understanding that under no circumstance will you fill narcotic prescriptions early, or without an in office visit

To take a person off narcotic medications, the rule is go slow.  You will do the same education as written above, as an explanation of why you don't want to subject them to the risks of narcotics when other, less risky regimens havce not been used.  I would decrease the dose by 20% per week, give frequent visits to monitor their pain (like weekly check-ins), use pain scales to quantify the pain and hold your ground.  You will lose some patients, and others will be grateful to have a doctor who cares about their recovery.  In either case, you will have practiced medicine that you can feel good about.

As far as specific guidelines, this is still very much a field in development.  However, these resources will be helpful to you:

Rights and Responsibilities of Healthcare Professionals in the use of Opioids for the Treatment of Pain

Pain in Addiction Medicine on the ASAM website (Amercian Society for Addiction Medicine)

Hope this helps!